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9 Access and Barriers to Care
Pages 413-456

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From page 413...
... that have been diagnosed with posttraumatic stress disorder (PTSD) and other mentalhealth disorders (see Chapter 4)
From page 414...
... . TABLE 9.1 Patient, Community, Health System and Provider Determinants of Access Dimension of Access Actual Access Perceived Access Examples of Measures Geographic Road travel distance and travel time Self-report of one's travel Distance to nearest to nearest provider or nearest provider or telehealth facility with telemedicine provider equipment; number and choice of providers Temporal Time delay between when services Self-reported time burden Appointment wait times are needed and how long it actual and temporal convenience takes to receive the service; length of receiving services of time to get an appointment or to communicate digitally with the provider; time spent waiting in the reception area, receiving the treatment, and wait time for next appointment Financial Eligibility and cost of utilizing the Influenced by perceptions Copayments services, including insurance of eligibility and premiums, out-of-pocket costs, and affordability opportunity costs, cost of digital connectivity, and other computer health applications.
From page 415...
... . The MHS provides direct care to most active-duty service members through military treatment facilities (MTFs)
From page 416...
... ; active duty (1.28 million, 14%) ; and National Guard and reserve family members (0.58 million, 6%)
From page 417...
... . In addition to active-duty members and their families, the following beneficiary groups are also eligible for coverage under TRICARE Prime: retired National Guard and reserve members (age 60 and receiving retired pay but not eligible for TRICARE for Life)
From page 418...
... 2 0.30 0.26 0.26 0.27 0.28 0.29 0.29 0.40 0.46 Number of Eligible Beneficiaries (Millions) 0.06 0.05 0.39 0.41 0.44 0.45 0.45 0.05 0.05 0.05 0.05 0.05 0.29 0.28 0.30 0.34 0.34 0.07 0.07 0.07 0.06 0.07 0.34 0.34 0.06 0.06 0.01 0.01 0.01 0.01 0.01 1 0.01 0.01 1.12 1.27 1.24 1.19 1.17 1.18 1.22 1.25 1.09 1.07 1.04 1.06 1.04 1.05 0 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 Active Duty Active Duty Family Members 2 1 0.30 0.29 0.32 0.35 0.29 0.26 0.26 0.19 0.19 0.16 0.15 0.17 0.19 0.18 0.09 0.10 0.11 0.12 0.09 0.09 0.01 0.07 0.07 0.07 0.08 0.08 0.09 0.09 0.03 0.02 0.02 0.02 0.03 0.02 0.02 0.02 0.02 0.01 0.01 0.01 0.01 0.01 0 0.07 0.08 0.06 0.07 0.08 0.09 0.08 0.10 0.11 0.09 0.09 0.10 0.10 0.10 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 Mobilized Guard/Reserve Family Members of Mobilized Guard/Reserve In Catchment and PRISM Area In Catchment Area, Not in PRISM Area Not in Catchment Area, in PRISM Area Not in Catchment or PRISM Area FIGURE 9.2 Trend in the number of eligible beneficiaries living in and out of MTF catchment and PRISM areas (year-end population)
From page 419...
... in support of a contingency operation, separated following a voluntary agreement to stay on active duty in support of contingency operation, received a sole survivorship discharge, or separated and agreed to become a member of Selected Reserve. Deactivated National Guard and reserve members who were called to active duty for at least 30 days in support of a contingency operation and their dependents are also usually eligible to receive health care coverage for 180 days through TAMP (Military.com, 2012a)
From page 420...
... , the Veterans Health Administration (VHA) , and the National Cemetery Administration (NCA)
From page 421...
... Health care is delivered through Veterans Affairs Medical Centers (VAMCs) that provide acute and long-term care delivery facilities through 152 hospitals; more than 800 ambulatory care clinics (CBOCs)
From page 422...
...  Subpriority b: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less Veterans eligible for enrollment: Non-service-connected and:  Subpriority c: Enrolled as January 16, 2003, and who remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status  Subpriority d: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less Veterans not eligible for enrollment: Veterans not meeting the criteria above:  Subpriority e: Noncompensable 0% service-connected  Subpriority g: Non-service-connected SOURCE: Department of Veterans Affairs website: http://www.va.gov/healthbenefits/resources/priority_groups.asp (accessed October 3, 2012)
From page 423...
... . VA Electronic Health Record In an effort to improve access through communication between health care provider and patient, the website MyHealtheVet was introduced by the VHA in 2003.
From page 424...
... Additionally, some reserve members might receive care from both DOD and VA, and although both use electronic health records, the two systems are not yet compatible.
From page 425...
... Electronic Health Records Successful transfer of medical records is a necessary component of the DOD-to-VA transition and, more broadly, a way in which to decrease fragmentation of care resulting from movements between health systems and providers. Electronic health records have the potential to facilitate communication between patients and providers, especially from differing health care systems, to improve coordination and reduce redundant care, medication errors, and costs (Kaelber and Pan, 2008; Ralston et al., 2007; Ross et al., 2004; Schnipper et al., 2009; Zhou et al., 2007)
From page 426...
... Women in the Military As noted in Chapter 4, women comprise about 14% of all active-duty military, and 17.6% of National Guard and reserves; about 12% of women veterans served in OEF, OIF, or OND.7 Historically, the research on the health of veterans has focused on the health consequences of combat service in men with little scientific research or longitudinal study of the health consequences of military service for women. Research that has examined gender differences is generally mixed, and a recent review (Street et al., 2009)
From page 427...
... (2012) conducted a retrospective study to examine gender differences in VA health care use among a national sample of newly returning OEF and OIF veterans with PTSD seeking care from 2001–2010.
From page 428...
... . Women veterans with delayed care were more likely to be OEF and OIF veterans, a high-priority group for VA enrollment, and to have experienced MST.
From page 429...
... . A small study of Puerto Rican OEF and OIF veterans and family members following deployment examined unmet health needs.
From page 430...
... . Rural Veterans Health disparities between rural and urban communities have been well documented (IOM, 2005)
From page 431...
... Veterans indicated that the same travel distance was more burdensome when seeking care for routine services (e.g., laboratory, podiatry) as compared to specialty care (e.g., cardiology, neurology)
From page 432...
... notes logistical challenges for veterans in accessing mental-health care, including difficulty in scheduling and coordinating appointments, long distances to facilities and other transportation challenges, cost of services, challenges in arranging child care or spousal support, and other time constraints. The section below begins with a discussion of stigma, a barrier that has been well documented in the military population as it relates to mental-health; additional barriers discussed include wait times, workforce capacity, and geographic accessibility.
From page 433...
... Findings indicate that 49% of National Guard members and 34% of their partners met screening criteria for one or more mental-health symptoms. Although 53% of the National Guard soldiers who met screening criteria reported getting some type of care, concerns about treatment influencing career advancement among service members was a barrier for those not seeking care.
From page 434...
... Positive experiences with mental-health providers improve the likelihood of seeking additional treatment. For example, studies have found that the use of mental-health services in National Guard troops was associated with previous mental-health care satisfaction and belief in treatment efficacy (Kehle et al., 2010; Pietrzak et al., 2009)
From page 435...
... and include shortages of uniformed mental-health specialty providers, long wait times, and unfilled training slots. Numerous studies have shown such organizational barriers to seeking care (Britt et al., 2008; Wright et al., 2009)
From page 436...
... It was also noted that providers in areas with the greatest density of National Guard troops were more likely to report that they were no longer accepting TRICARE coverage. With regard to veterans' access to mental-health services, some states have established public–private collaborative programs so veterans can seek care in areas of poor availability of VHA mental-health services.
From page 437...
... . Geographic Accessibility Most active-duty service members and families live within 20 miles of a medical treatment facility and within 40 miles of inpatient services; however, less than 50% of National Guard and reserve members live within those described areas (DOD, 2011b)
From page 438...
... Telepsychiatry offers a mechanism for VA mental-health professionals to treat returning OEF and OIF veterans with one or more mental-health diagnosis, and other medical comorbidities, in areas where there is limited access to timely evaluation and treatment. The authors examined data from telepsychiatry encounters at the Womack WTC (North Carolina Womack Army Medical Center)
From page 439...
... Conclusions indicate that telehealth interventions had distinct advantages, such as enhanced patient access to treatments, a medium for patient–provider communication, access to electronic medical record information, and the facilitation of collaborative care. The studies demonstrated that frequent contact between patient and provider fostered a therapeutic alliance and may increase patient satisfaction and willingness to participate in collaborative care.
From page 440...
... Although its acceptance among active-duty service members and veterans is mixed, it appears to be more positive than negative. Telemedicine offers rural veterans the opportunity to access health care that they might not otherwise obtain and reduces wait time and addresses workforce capacity issues.
From page 441...
... Two of these programs are highlighted below. Battlemind Battlemind -- now referred to as Resilience Training -- is a training program originally developed by Army researchers to ease returning troops' transition from combat to civilian life.
From page 442...
... . Platoons were randomly assigned to Battlemind training, Battlemind debriefing, or the Army's standard postdeployment stress education.
From page 443...
... Fragmentation of care in both those systems does occur. Electronic health records offer the promise of minimizing fragmentation of care, but the DOD and VA have not yet integrated their health records.
From page 444...
... The committee recommends improved coordination of care and services between the Department of Defense and the Department of Veterans Affairs medical treatment facilities, including the completion of an interoperable or single combined electronic health record for all care that begins with entry into military service and continues throughout care in the Department of Veterans Affairs system after transition. Stigma is still a problem for military personnel in care or seeking care for mental-health or substance-abuse problems.
From page 445...
... In addition, adverse long-term outcomes, such as death and preventable hospitalizations, are more common for veterans who seek care at facilities that have longer wait times than for veterans at facilities that have shorter wait times. Poor availability and misdistribution of mental-health specialists in many parts of the United States, especially in rural areas, present substantial barriers to OEF and OIF veterans' access to mental-health care.
From page 446...
... 2002. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Disparities and context.
From page 447...
... 2009. Quality Initiatives Undertaken by the Veterans Health Administration.
From page 448...
... 2005. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics.
From page 449...
... 2010. Review of Veterans Health Administration telemedicine interventions.
From page 450...
... 2008. Effects of military trauma exposure on women veterans' use and perceptions of Veterans Health Administration care.
From page 451...
... 1997. Posttraumatic stress disorder associated with peacekeeping duty in Somalia for US military personnel.
From page 452...
... 2010. Embracing a health services research perspective on personal health records: Lessons learned from the VA My Healthevet system.
From page 453...
... 2004a. The American Indian veteran and posttraumatic stress disorder: A telehealth assessment and formulation.
From page 454...
... 2012. Veterans Health Administration: Review of Veterans' Access to Mental-health Care.
From page 455...
... 2006. Physical and mental-health and access to care among nonmetropolitan Veterans Health Administration patients younger than 65 years.


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